PROCALCITONIN: Contributing to IMPROVED CLINICAL DECISION MAKING - PowerPoint PPT Presentation

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PROCALCITONIN: Contributing to IMPROVED CLINICAL DECISION MAKING

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Title: PROCALCITONIN: Contributing to IMPROVED CLINICAL DECISION MAKING Subject: PCT in ER Author: Sean-Xavier Neath Last modified by: yasergad Created Date – PowerPoint PPT presentation

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Title: PROCALCITONIN: Contributing to IMPROVED CLINICAL DECISION MAKING


1
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2
Clinical Implication of Serum Procalcitonin in
Sepsis and pneumonia
Dr. Yaser Gad
Lecturer of chest diseases, Assuit faculty of
medicine
3
Sepsis
  • The most common cause of death in intensive care
    units
  • Mortality rate up to 50 depending on severity.
  • Early diagnosis and intervention markedly reduce
    the mortality

4
Infection Source in Severe Sepsis
Angus DC et al. Crit Care Med. 2001 291303
5
Pneumonia
The major infection-related cause of death in
developed countries
10 to 20 admitted to the intensive care unit
20 to 50 of them will ultimately die
6
Fight as much as you can
  • Early diagnosis and intervention
  • Differentiate between infectious and non
    infectious case of systemic inflammation


7
  • Early diagnosis is essential to
  • Administer the correct treatment
  • Avoid unnecessary antibiotic use
  • Reducing the morbidity, mortality
  • And decrease care-related costs.

(1)
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
8
Delayed diagnosis
  • Delays treatment
  • Increases hospital length-of-stay
  • Increases costs
  • Increased mortality

9
Delayed intervention can be fatal
Sebat CCM 2007 35 2568
10
It is very important to differentiate between
infectious and non infectious case of systemic
inflammation
(2)
11
Inability to differentiate between infectious and
non infectious causes
Unplanned use of antibiotics
Antibiotic resistance
12
Acute exacerbations
70 are infectious in origin .
2030 related to bacteria detected by sputum
culture
viruses are detected in gt50 of exacerbations
Bacteria are isolated from the respiratory tract
of only 50 of patients
Chen et al, 2008 Chinese Medical Journal, 2008,
Dauben et al., BMC Infect Dis. 2008 8 145.
13
  • Antibiotics were found to have been prescribed in
    85 of patients admitted for AE-COPD to 360
    hospitals throughout the USA
  • Drug costs accounted for more than 70 of the
    total costs AE-COPD

Chen et al, 2008 Chinese Medical Journal, 2008,
14
Antibiotic sensitivity for AECOPD in Upper Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
15
Antibiotic sensitivity for CAP and HAP in Upper
Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
16
Acute phase reactants
Capable of demonstrating the inflammation
But can not
differentiate between bacterial and nonbacterial
inflammation
17
CRP and leukocyte count do not have sufficient
specificity in differentiating between bacterial
infections, non-infectious systemic inflammations
or viral infections.
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
18
  • Because most microbiological test results are not
    available for 24 h, a sensitive and specific
    marker of systemic infection would be useful.

Hausfater et al, 2002. Clinical Infectious
Diseases Volume 34, Issue 7Pp. 895-901 Reimer et
al. Clinical Microbiol Rev 1997 10444-65.
19
  • We are in need for a simple and rapid laboratory
    method to
  • Guide antibiotic use
  • Predict the prognosis
  • Predict mortality
  • Differentiate between infectious and non
    infectious causes of systemic inflammation

20
Recently,
(PCT) levels appears to be useful in order to
minimize this problem. The sensitivity and
specificity of PCT in bacterial infections were
found to be 92.6 and 97.5
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
21
Invasion by pathogenic bacteria
Bacterial toxins and cytokines
Stimulate PCT production in all paraynchymal cells
Adapted from Christ-Crain et al. 2005
22
IFN-g
Viral infection
Decreases PCT production
23
VALUES OF PROCALCITONIN IN INFECTION
24
1- PCT LEVEL INCREASE INCREASED SIGNIFICANCE OF
BACTERIAL INFECTION
25
2- Differentiates between bacterial contamination
and real bacterial infection
  • PCT may help discriminate blood stream infections
    from blood culture contamination due to
    coagulase-negative staphylococci

Schuetz P. et al., Infection 200735 (5) 352-5
26
3- Predicts bacteremia
  • PCT measurement demonstrated the potential to
    reduce the number of blood cultures

Muller et al. CHEST July 2010
27
4- PROCALCITONIN CORRELATES TO THE SEVERITY OF
THE INFECTION
Pneumonia
Sepsis
Harbarth S et al. Am J Respir Crit Care Med 2001,
164 396-402 Meisner M et al., Critical Care
1999, 3(1) 45-50 Krüger S. et al., Eur Respir J
2008 31 349355
28
5- Evaluates the prognosis
PCT
PCT
  • Low PCT levels identify patients presenting in
    the ED that have a low risk for mortality

Huang, et.al., Annals of Emergency Medicine, Vol
51, March 2008
29
6- Evaluates patient response to antibiotics
  • Decreasing PCT levels indicate effective
    treatment of the underlying infection
  • Persistently elevated PCT levels indicate a
    possible treatment failure

Stueber, F. University of Bonn, Lecture at
ISICEM, Brussels 2001
30
PCT guidance in antibiotic usage Effects on
length of stay
  • Effect of PCT-guided management in patients with
    sepsis on ICU length of stay

Nobre V. et alAM Resp Crit Care Med 2008
177498-505
31
7- Sort out the etiology of the fever in patients
with the fever of unknown origin (FUO) syndrome



  • PCT levels do not increase in some of the disease
    entities that cause the FUO syndrome, e.g.,
    Still's disease, systemic lupus erythematosus,
    and inflammatory bowel disease

32



  • PCT levels are not affected by the patient's use
    of nonsteroidal anti-inflammatory agents or
    glucocorticoids

If so,
  • PCT levels remain a valuable marker of the host
    inflammatory response even when nonsteroidal
    anti-inflammatory drugs and corticosteroids are
    used

33
Diagnostic accuracy of PCT compared to other
biomarkers used in sepsis
  • PCT levels accurately differentiate sepsis from
    noninfectious inflammation
  • PCT has been demonstrated to be the best marker
    for differentiating patients with sepsis from
    those with systemic inflammatory reaction not
    related to infectious cause

Simon L. et al. Clin Infect Dis. 2004
39206-217.
34
False negative results
  • Low PCT levels in the presence of bacterial
    infection may occur
  • Early course of infection Re-measure in 6-12hrs
  • Subacute Endocarditis
  • Localized infections

35
False positive results
  • Cirrhosis
  • Pancreatitis
  • Mesenteric infarction (ischemic bowel)
  • Cardiogenic shock, and hypotension during surgery
  • Burns
  • Pulmonary edema and pulmonary aspiration

36
In conclusion
  • PCT is usefull to diffrentiate between bacterial
    and non bacterial infection
  • Differentiates between bacterial contamination
    and real bacterial infection
  • Predicts bacteremia

37
  • PCT level correlates with the severity of
    infection in sepsis and pneumonia
  • Evaluates the prognosis
  • Evaluates patient response to antibiotics
  • Sort out the etiology of the fever in patients
    with the fever of unknown origin (FUO) syndrome

38
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